H.R. 1 Impact on Coding
Timothy Powell, CPA, CHCP
December 15, 2025
H.R. 1 doesn’t directly rewrite ICD-10 or CPT, but it does change the environment in which you’re coding. The impact is mostly indirect – through
Anticipated changes in the CC/MCC designations were delayed.
EDITOR’S NOTE: Senior healthcare consultant Laurie Johnson reported this story live during Aug. 6 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting.
The Centers for Medicare and Medicaid (CMS) Inpatient Prospective Payment System (IPPS) FY20 Final Rule was released on August 2, 2019. There were some anticipated changes that were a no-show in the 2,273 pages of the final rule that can be found. This article discusses the Medicare Severity Diagnosis Related Groups (MS-DRGs) changes with a focus on the overall changes.
The CC/MCC Re-assignment
The anticipated changes in the CC/MCC designations were delayed. CMS received many comments regarding the suggested 1,492 changes in the CC/MCC designations that appeared in Proposed Rule. Due to the increased comments, CMS decided to make some minor changes to the CC/MCC designations and review the topic for FY21.
The non-CC to CC changes that were finalized include eighteen codes that appear in the Z16 category which covers resistance to various drugs. The Social Determinant of Health code Z59.0 (Homelessness) is still designated as non-CC. There was no additional information on the Social Determinants of Health in this Final Rule.
There appear to be 14,598 CCs and 3,249 MCCs for FY20 including the CC/MCC designations for the new diagnosis codes.
The MS-DRG Changes
The overall relative values for FY20 have increased over the relative values for FY19. There are seven suggested MS-DRG changes that increase over FY19. The table below provides more detail regarding the shifts and specific MS-DRGs with the associated relative weights by topic.
|
Topic |
Actions |
Original MS-DRG |
FY19 RW |
New MS-DRG |
FY20 RW |
|
Peripheral ECMO |
Reassign peripheral ECMO to MS-DRG 003 Retitle MS-DRGs 207, 291, 296, and 870 |
207 291 296 870 |
5.5965 1.3454 1.5355 6.2953 |
003 |
18.9539 |
|
Allogeneic Bone Marrow Transplant |
Reassign some transfusion codes Delete 128 clinically invalid transfusion codes from PCS |
014 |
11.9503 |
016 017 |
6.8852 4.4474 |
|
Carotid Artery Stents |
Remove 46 PCS codes (carotid artery w/o stent or other vessels) from MS-DRG 034, 035, 036 Remove 96 codes (dilation carotid artery w/stent) from MS-DRGs 037, 038, 039 Move 6 proc code (dilation of carotid artery w/stent that was missing) to MS-DRG 034, 035, 036 |
034 035 036 |
3.5998 2.2203 1.7260 |
037 038 039 |
3.2433 1.6752 1.1313 |
|
Pulmonary Embolism |
Re-assign secondary diagnosis of I26.01, I26.02, I26.09 Re-title MS-DRG “Pulmonary Embolism w/MCC or Acute Cor Pulmonale” |
176 |
0.8990 |
175 |
1.4444 |
|
Transcatheter Mitral Valve Repair w/Implant |
Move endovascular supplement procedures. Create new MS-DRGs for endovascular non-supplement procedures. |
216 217 218 219 220 221 228 229 273 274 |
10.2194 6.9849 5.5351 7.6916 5.2053 4.6074 6.5762 4.6484 3.6525 2.9783 |
266 267 319 320 |
7.1214 5.6756 4.1007 2.3477 |
|
Revision of Pacemaker Lead |
Add 02H60JZ as non-procedure that impacts DRG assignment |
260 261 262 |
3.6915 1.9918 1.6309 |
260 261 262 |
3.6996 1.9485 1.6776 |
|
Knee Proc w/PDx of Infection |
Add A54.42, M00.9, A18.02, M01.X61, M01.X62, M01.X69, M71.061, M71.062, M71.069, M71.161, M71.162, M71.169 Remove several diagnoses from 485, 486, 487 |
548 549 550 |
2.0672 1.2442 0.9238 |
485 486 487 |
3.2790 2.1506 1.6072 |
|
Neuromuscular Scoliosis |
Move M41.40, M41.44, M41.45, M41.46, M41.47 |
459 460 |
6.3848 4.0375 |
456 457 458 |
9.0812 6.5133 4.6939 |
|
Secondary Scoliosis/Kyphosis |
Move M41.50, M41.54, M41.55, M41.56, M41.57, M40.10, M40.14, M40.15 34 Diagnosis codes for the cervical spine with being removed from 456, 457, 458 |
459 460 |
6.3848 4.0375 |
456 457 458 |
9.0812 6.5133 4.6939 |
|
Extracorporeal Shockwave Lithotripsy |
Delete MS-DRGs 691, 692 Update titles for 693, 694 |
691 692 |
1.6242 1.1306 |
693 694 |
1.1723 0.6794 |
|
Other specified conditions affecting pregnancy, childbirth, and the puerperium (O99.89) |
Re-classify as an antepartum condition |
769 (w/OR) 776 (w/o OR) |
1.4579 0.6590 |
817 818 819 831 832 833 |
0.7979 5.7167 2.2323 0.5321 5.8425 2.0282 |
|
Factors Influencing Health Status & Other Contacts with Health Services (R93.89) |
Re-assign from MDC 5 to MDC 23 |
MDC 5 302 303 |
1.0695 0.6655 |
MDC 23 947 948) |
1.0889 0.7409 |
|
Diagnostic Imaging of Male Anatomy |
Move R93.811, R93.812, R93.819 |
302 303 |
1.0695 0.6655 |
729 730 |
2.1919 1.3742 |
Changes to MS-DRGs 981 – 983 and 987 – 989
CMS routinely reviews the diagnosis and procedure codes that are grouping to the MS-DRGs 981-983 and 987 – 989. These MS-DRGs cover the diagnosis and procedure mismatches. The goal of the annual review is to reduce the number of situations that are assigned to these MS-DRGs.
The following table displays the topics that are covered in the MS-DRGs 981 – 983 and 987-989. Included in the table are a short description of the change, and the MS-DRGs assigned in FY19 with associated relative weight is compared to the proposed MS-DRG assigned in FY20 with the associated proposed relative weight.
|
Topic |
Actions |
Original MS-DRG |
FY19 RW |
FY20 MS-DRG |
FY20 RW |
|
Gastrointestinal Stromal Tumor (GIST) with stomach and/or small intestine excision |
Move diagnosis codes to MDC 6 |
981 982 983 |
4.3705 2.4529 1.5691 |
326 327 328 |
5.5899 2.7418 1.6480 |
|
Peritoneal Dialysis Catheters |
Add procedure codes for insertion, removal, or revision of peritoneal dialysis catheter to MDC 21 |
981 982 983 |
4.3705 2.4529 1.5691 |
907 908 909 |
1.3187 1.4763 0.8617 |
|
Bone Excision with Pressure Ulcers |
Add procedure codes for excision of sacrum, pelvic bones, and coccyx to MS-DRGs 579, 580, 581 |
981 982 983 |
4.3705 2.4529 1.5691 |
579 580 581 |
2.9861 1.6087 1.2548 |
|
Lower Extremity Muscle & Tendon Excision |
Add procedure codes for excision of muscle and tendon to DRGs 622, 623, 624 |
981 982 983 |
4.3705 2.4529 1.5691 |
622 623 624 |
3.7755 1.9526 1.1020 |
|
Insertion of Feeding Device |
Move 0DH60UZ from MDC 1 |
981 982 983 |
4.3705 2.4529 1.5691 |
040 041 042 |
3.9404 2.3715 1.8483 |
|
Insertion of Feeding Device |
Move 0DH60UZ from MDC 10 |
981 982 983 |
4.3705 2.4529 1.5691 |
628 629 630 |
3.6893 2.3228 1.4488 |
|
Basilic Vein Reposition in Chronic Kidney Disease |
Add procedure codes to MDC 11 |
981 982 983 |
4.3705 2.4529 1.5691 |
673 674 675 |
3.5746 2.4442 1.6320 |
|
Colon Resection with Fistula |
Add procedure code 0DTN0ZZ to MDC 11 |
981 982 983 |
4.3705 2.4529 1.5691 |
673 674 675 |
3.5746 2.4442 1.6320 |
|
Finger Cellulitis |
Add procedure codes for phalanx excision or resection to MDC 9 |
981 982 983 |
4.3705 2.4529 1.5691 |
579 580 581 |
2.9861 1.6087 1.2548 |
|
Gastric Band Procedures for Complications/ Infections |
Add procedure code 0DW64CZ and 0DP64CZ to MDC 6 |
987 988 989 |
3.3326 1.6931 1.0407 |
326 327 328 |
5.2708 2.5729 1.5750 |
|
Occlusion of Left Renal Vein |
Add procedure code 06LB3DZ to MDC 12 |
981 982 983 |
4.3705 2.4529 1.5691 |
715 716 717 |
1.7643 1.2194 1.8049 |
|
Occlusion of Left Renal Vein |
Add procedure code 06LB3DZ to MDC 13 |
981 982 983 |
4.3705 2.4529 1.5691 |
749 750 |
1.7619 1.0238 |
|
Peritoneal Dialysis Catheters |
Move procedures codes for removal, revision, and insertion of peritoneal dialysis catheters |
981 982 983 |
4.3705 2.4529 1.5691 |
907 908 909 |
1.3187 1.4763 0.8617 |
In summary, comments on the Proposed Rule made a big difference in the Final Rule. The comments were read and made a difference. CMS has tabled many of the CC/MCC designation changes. Additional feedback regarding any suggested changes for IPPS FY21 must be submitted by Nov. 1, 2019.
H.R. 1 doesn’t directly rewrite ICD-10 or CPT, but it does change the environment in which you’re coding. The impact is mostly indirect – through
Anyone who has worked within the scope of hospital case/utilization management for any period of time has heard of the Centers for Medicare & Medicaid
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
